1. Lung Cancer Update 16 January 2019
Trevor Rogers

2. Introduction Demography and other risk factors
How to diagnose lung cancer
Does the chest X-ray deserve its bad rep?
Results of our local initiative to increase chest X-ray referral rates-El Cid

3. It’s a Killer –if not caught young

4. Commonest cause of cancer death in both sexes
Just over 20% cases survive 1 year
5.5% 5-year survival (≈cure):
Most cases incurable due to advanced stage at presentation

5. Commonest cause of cancer death in both sexes
Just over 20% cases survive 1 year
5.5% 5-year survival (≈cure):
Most cases incurable due to advanced stage at presentation
Figures are 5-10% worse than Europe and USA

6. How to spot at this stage..

7. How to spot at this stage..
before this happens...

8. How to spot at this stage..
before this happens...

9. Lung cancer rates per 100,000
men
women
Doncaster 43 28
England 34 20

10. How to identify lung cancer
Who is at high risk?
rare below 50
increasingly common >60
COPD a major risk factor

11. Other risk factors Smoking (about 10% never smoked) Other Radiotherapy
Previous respiratory tract cancer
Asbestosis
Pulmonary fibrosis
Toxins including passive smoking FH

12. Diagnosis in primary care
most of the time to diagnosis is accounted for delays by patient seeking attention or in primary care
i.e. the time taken to obtain a primary care chest X-ray
The chest X-ray in symptomatic lung cancer
Contrary to previous dogma, it is not intrinsic to the disease that the interval between the onset of symptoms and the presence of a diagnosable cancer is short. Evidence is emerging confirming that patients suffer lung cancer symptoms for prolonged periods before diagnosis.19;20 It is also clear that most of the overall time to diagnosis is accounted for delays by patient seeking attention or in primary care, with time following referral accounting for relatively much less time.21 These data support the introduction of measures to facilitate early presentation, including using social marketing techniques to educate patients and their primary care teams, for example on the symptoms recommended by NICE for an urgent chest X-ray.
The lack of specificity of a chest X-ray reported as suspicious of lung cancer means that it is usually necessary to perform more sophisticated diagnostic procedures, before a definitive diagnosis and certainly before treatment can be decided upon. The chest X-ray is acting in this sense as a preliminary screening test to identify a population requiring further investigation. The problem with this approach is that a good screening test should produce few false negatives (i.e. have a high sensitivity). The evidence for the sensitivity of the chest X-ray from the American mass screening data referred to above gives cause for concern, but there the population concerned was asymptomatic, American, and relied on older technology. Sensitivity in the reporting of radiographs from symptomatic patients will depend on the size and location of the tumour, which will vary according to the extent of the disease (likely to be more advanced in symptomatic cases), the presence or otherwise of intercurrent lung disease, the availability of prior X-rays for comparison and not least the skill of the reporting radiologist (each of whom will have varying thresholds for raising the possibility of lung cancer- i.e. having his/her own sensitivity and specificity). There is some evidence that a single chest X-ray may have a relatively poor negative predictive value (i.e. confidence that if it is reported to be normal, the disease is genuinely absent) in a UK population. In the study of Shapley et al,22 in the 12 months prior to the diagnosis, 38 of 164 lung cancer patients had previously had a negative X-ray. Negative X-rays were less common in the 90 days before diagnosis, whilst films obtained earlier were quite frequently reported to be normal. These data indicate a 77% overall sensitivity for a single chest X-ray, if we accept that the disease was meaningfully present when all of the X-rays were obtained. The implication is that if a film has been normal, in the case of continuing suspicion of lung cancer, the appropriate strategy may be either to repeat the film, at say 2-3 months, or to refer immediately to secondary care for consideration of bronchoscopy and/or CT scanning.

13. How reliable is the chest X-ray?
When reported as suspicious usually need CT before definitive diagnosis established
(60% of patients we advise target appointment for have LC)
Sensitivity depends on
tumour size and location
presence of intercurrent lung disease
the availability of prior X-rays
the reporting radiologist
The chest X-ray in symptomatic lung cancer
Contrary to previous dogma, it is not intrinsic to the disease that the interval between the onset of symptoms and the presence of a diagnosable cancer is short. Evidence is emerging confirming that patients suffer lung cancer symptoms for prolonged periods before diagnosis.19;20 It is also clear that most of the overall time to diagnosis is accounted for delays by patient seeking attention or in primary care, with time following referral accounting for relatively much less time.21 These data support the introduction of measures to facilitate early presentation, including using social marketing techniques to educate patients and their primary care teams, for example on the symptoms recommended by NICE for an urgent chest X-ray.
The lack of specificity of a chest X-ray reported as suspicious of lung cancer means that it is usually necessary to perform more sophisticated diagnostic procedures, before a definitive diagnosis and certainly before treatment can be decided upon. The chest X-ray is acting in this sense as a preliminary screening test to identify a population requiring further investigation. The problem with this approach is that a good screening test should produce few false negatives (i.e. have a high sensitivity). The evidence for the sensitivity of the chest X-ray from the American mass screening data referred to above gives cause for concern, but there the population concerned was asymptomatic, American, and relied on older technology. Sensitivity in the reporting of radiographs from symptomatic patients will depend on the size and location of the tumour, which will vary according to the extent of the disease (likely to be more advanced in symptomatic cases), the presence or otherwise of intercurrent lung disease, the availability of prior X-rays for comparison and not least the skill of the reporting radiologist (each of whom will have varying thresholds for raising the possibility of lung cancer- i.e. having his/her own sensitivity and specificity). There is some evidence that a single chest X-ray may have a relatively poor negative predictive value (i.e. confidence that if it is reported to be normal, the disease is genuinely absent) in a UK population. In the study of Shapley et al,22 in the 12 months prior to the diagnosis, 38 of 164 lung cancer patients had previously had a negative X-ray. Negative X-rays were less common in the 90 days before diagnosis, whilst films obtained earlier were quite frequently reported to be normal. These data indicate a 77% overall sensitivity for a single chest X-ray, if we accept that the disease was meaningfully present when all of the X-rays were obtained. The implication is that if a film has been normal, in the case of continuing suspicion of lung cancer, the appropriate strategy may be either to repeat the film, at say 2-3 months, or to refer immediately to secondary care for consideration of bronchoscopy and/or CT scanning.

14. Screening Negative CXR screening studies from the 1980s
Indicated and recently confirmed that have no value in screening
CT screening shown to improve prognosis but at huge cost
As for many screening programmes bedevilled by “overdiagnosis” –i.e. finding tumours with no lethal potential

15. The limitations of a negative chest X-ray report: Shapley et al
77% sensitivity for a single chest X-ray in the 12 months before diagnosis
if a film has been normal, in the case of continuing suspicion of lung cancer, should either
repeat the film, at say 2-3 months
or refer to secondary care for consideration of CT scan
The chest X-ray in symptomatic lung cancer
Contrary to previous dogma, it is not intrinsic to the disease that the interval between the onset of symptoms and the presence of a diagnosable cancer is short. Evidence is emerging confirming that patients suffer lung cancer symptoms for prolonged periods before diagnosis.19;20 It is also clear that most of the overall time to diagnosis is accounted for delays by patient seeking attention or in primary care, with time following referral accounting for relatively much less time.21 These data support the introduction of measures to facilitate early presentation, including using social marketing techniques to educate patients and their primary care teams, for example on the symptoms recommended by NICE for an urgent chest X-ray.
The lack of specificity of a chest X-ray reported as suspicious of lung cancer means that it is usually necessary to perform more sophisticated diagnostic procedures, before a definitive diagnosis and certainly before treatment can be decided upon. The chest X-ray is acting in this sense as a preliminary screening test to identify a population requiring further investigation. The problem with this approach is that a good screening test should produce few false negatives (i.e. have a high sensitivity). The evidence for the sensitivity of the chest X-ray from the American mass screening data referred to above gives cause for concern, but there the population concerned was asymptomatic, American, and relied on older technology. Sensitivity in the reporting of radiographs from symptomatic patients will depend on the size and location of the tumour, which will vary according to the extent of the disease (likely to be more advanced in symptomatic cases), the presence or otherwise of intercurrent lung disease, the availability of prior X-rays for comparison and not least the skill of the reporting radiologist (each of whom will have varying thresholds for raising the possibility of lung cancer- i.e. having his/her own sensitivity and specificity). There is some evidence that a single chest X-ray may have a relatively poor negative predictive value (i.e. confidence that if it is reported to be normal, the disease is genuinely absent) in a UK population. In the study of Shapley et al,22 in the 12 months prior to the diagnosis, 38 of 164 lung cancer patients had previously had a negative X-ray. Negative X-rays were less common in the 90 days before diagnosis, whilst films obtained earlier were quite frequently reported to be normal. These data indicate a 77% overall sensitivity for a single chest X-ray, if we accept that the disease was meaningfully present when all of the X-rays were obtained. The implication is that if a film has been normal, in the case of continuing suspicion of lung cancer, the appropriate strategy may be either to repeat the film, at say 2-3 months, or to refer immediately to secondary care for consideration of bronchoscopy and/or CT scanning.

16. NICE Guideline:
The diagnosis and treatment of lung cancer: February 2005

17. Who knows when a chest X-ray is recommended by NICE?
Do you try to comply?

18. Who would do a chest X-ray?
60-year-old man with a 3-week history of cough?

19. Who would do a chest X-ray?
60-year-old man with a 3-week history of cough having started with a flare up of his known COPD?

20. Who would do a chest X-ray?
60-year-old man with COPD
2-week history of dry irritable cough

21. Who would do a chest X-ray?
50-year-old non-smoker with cough for a couple of weeks

22. Who would do a chest X-ray?
75-year-old man with vague, left-sided chest pain for about 2 weeks
O/E looks well and nil of note to find

23. Who would do a chest X-ray?
75-year-old man with vague, left-sided chest pain for about 2 weeks, feeling lethargic
O/E looks cachectic

24. Main issue in primary care is
ordering a chest x-ray when lung cancer is a possibility:

25. Presentations for an urgent chest X-ray:
“Early” symptoms –most important

26. Presentations for an urgent chest X-ray:
“Early” symptoms –most important
Haemoptysis

27. Presentations for an urgent chest X-ray:
“Early” symptoms –most important
Haemoptysis
Unexplained

28. Presentations for an urgent chest X-ray:
“Early” symptoms –most important
Haemoptysis
Unexplained or persistent (>3 weeks):

29. Presentations for an urgent chest X-ray:
“Early” symptoms –most important
Haemoptysis
Unexplained or persistent (>3 weeks):
cough
chest/shoulder pain
dyspnoea

30. Presentations for an urgent chest X-ray:
“Early” symptoms –most important
Haemoptysis
Unexplained or persistent (>3 weeks):
cough
chest/shoulder pain
dyspnoea
Investigation of
weight loss
chest signs
hoarseness
finger clubbing
features suggestive of metastasis from a lung cancer (for example, in brain, bone, liver or skin)
cervical/supraclavicular lymphadenopathy

31. Urgent 2-week wait referral, irrespective of chest x-ray result: High clinical suspicion of lung cancer

32. Urgent 2-week wait referral, irrespective of chest x-ray result: High clinical suspicion of lung cancer
(1) persistent haemoptysis in
(2) smokers/ex-smokers
(3) >40 years old

33. Urgent 2-week wait referral, irrespective of chest x-ray result: High clinical suspicion of lung cancer
(1) persistent haemoptysis in
(2) smokers/ex-smokers
(3) >40 years old
Signs of superior vena caval obstruction (swelling of the face/neck + fixed elevation of JVP)
Stridor

34. Urgent 2-week wait referral, irrespective of chest x-ray result: High clinical suspicion of lung cancer
(1) persistent haemoptysis in
(2) smokers/ex-smokers
(3) >40 years old
Signs of superior vena caval obstruction (swelling of the face/neck + fixed elevation of JVP)
Stridor

35. Summary. Indications for a 2ww referral:
High probability chest x-ray OR
All 3 of the following features:
(1) persistent haemoptysis in
(2) smokers/ex-smokers
(3) >40 years old
SVCO
Stridor

36. Presentation does affect outcome

37. Presentation does affect outcome

38. Cough vs. other presentations
Median survival
398 vs. 183 days p<0.001

39. Cough vs. abnormal CXR
Median survival
398 vs 369 days p=0.9537

40. Cough
Associated with good prognosis –unlikely due only to be lead-time bias

41. How to diagnose lung cancer
Easy when advanced

42. How to diagnose lung cancer
The trick is to identify at a radically treatable stage
Perfectly possible to have lung cancer and be well -and this is when we want to see patients!

43. How to diagnose lung cancer
Do a chest X-ray!

44. How to diagnose lung cancer
“Get in the right guideline”:
When you diagnose an exacerbation of COPD, consider if this patient is meeting the lung cancer criteria for doing a chest X-ray

45. 45

46. Diagnosis - rates and stage
116 diagnoses of lung cancer in the 6 months before the campaign.
126 in the same period following the campaign
Increase from 10 to 14% in Stage I cancers pre vs. post campaign (but numbers small)
Resection rate 13.7% (13.2% in 2007)

48. Conclusion We have not been picking up enough early (curable) cancers
The chest x-ray is the key investigation in primary care: please use it –& we have capacity!
It appears uptake is increasing and early data suggest brought forward the time to diagnosis
This is an important test to see if UK lung cancer outcomes can be improved in this simple way